Nursing Elites

1. A client with deep vein thrombosis (DVT) in the left leg is on a heparin protocol. Which intervention is most important for the nurse to include in this client's plan of care?

• A. Observe for bleeding side effects related to heparin therapy.
• B. Assess blood pressure and heart rate at least every 4 hours.
• C. Measure calf girth to evaluate edema in the affected leg.
• D. Encourage mobilization to prevent pulmonary embolism.

Correct answer: A

Rationale: The correct answer is to 'Observe for bleeding side effects related to heparin therapy.' This is the most crucial intervention for a client with deep vein thrombosis (DVT) on a heparin protocol. Heparin, being an anticoagulant, increases the risk of bleeding as a side effect. Therefore, close monitoring for signs of bleeding, such as bruising, petechiae, or blood in stool or urine, is essential to prevent severe complications. While assessing blood pressure and heart rate (Choice B) is important, it is not as critical as monitoring for bleeding. Measuring calf girth (Choice C) may help evaluate edema but is not as vital as observing for bleeding complications. Encouraging mobilization (Choice D) is beneficial for preventing complications like pulmonary embolism, but in this scenario, monitoring for bleeding takes precedence due to the immediate risk associated with anticoagulant therapy.

2. When implementing a disaster intervention plan, which intervention should the nurse implement first?

• A. Initiate the discharge of stable clients from hospital units
• B. Identify a command center where activities are coordinated
• C. Assess community safety needs impacted by the disaster
• D. Instruct all essential off-duty personnel to report to the facility

Correct answer: B

Rationale: When implementing a disaster intervention plan, the first step the nurse should take is to identify a command center where activities are coordinated. This step is crucial for ensuring an organized and effective disaster response. Option A, initiating the discharge of stable clients, is not a priority during the initial phase of disaster response. Option C, assessing community safety needs, usually follows setting up a command center. Option D, instructing off-duty personnel to report, may be necessary but is not the primary intervention at the beginning of a disaster situation.

3. A 37-year-old client diagnosed with chronic kidney disease (CKD) is being treated for renal osteodystrophy. Which nursing diagnosis is most likely to be included in this client’s plan of care?

• A. High risk for infection related to subclavian catheter
• B. High risk of injury related to ambulation
• C. Knowledge deficit related to a high-protein diet
• D. Hygiene self-care deficit related to uremic frost

Correct answer: D

Rationale: The correct answer is D. Uremic frost is a condition in which urea and other waste products are excreted through the skin, leaving a powdery residue. This indicates poor hygiene and self-care, common issues in patients with CKD and renal osteodystrophy. Proper hygiene measures are essential to prevent complications. Choices A, B, and C are less likely to be included in the plan of care for a CKD patient with renal osteodystrophy. Choice A is more related to a vascular access issue, choice B is more related to mobility concerns, and choice C is more related to dietary education.

4. What action should the nurse implement for a female client with cancer who has a good appetite but experiences nausea whenever she smells food cooking?

• A. Encourage family members to cook meals outdoors and bring the cooked food inside
• B. Advise the client to replace cooked foods with a variety of different nutritional supplements
• C. Assess the client’s mucus membranes and report the findings to the healthcare provider
• D. Instruct the client to take an antiemetic before every meal to prevent excessive vomiting

Correct answer: A

Rationale: The correct action for the nurse to implement is to encourage family members to cook meals outdoors and bring the cooked food inside. This strategy can help reduce the smell of cooking food and potentially alleviate the client's nausea triggered by food smells. Assessing the client's mucus membranes (choice C) is not directly related to the client's symptom of nausea triggered by food smells. Instructing the client to take an antiemetic before every meal (choice D) may not address the root cause of the issue, which is the smell of cooking food. Advising the client to replace cooked foods with nutritional supplements (choice B) does not address the immediate problem of food odors triggering nausea.

5. After assessing an older adult with a suspected cerebrovascular accident (CVA), the nurse documents the client's right upper arm weakness and slurred speech. When the client complains of a severe headache and nausea, and the neurological assessment remains unchanged, which action should the nurse implement first?

• A. Administer an oral analgesic with antiemetic
• B. Collect blood for coagulation times
• C. Send the client for a computed tomography scan of the brain
• D. Obtain a history of medication use, recent surgery, or injury

Correct answer: C

Rationale: In this scenario, the priority action for the nurse is to send the client for a computed tomography (CT) scan of the brain. A CT scan is crucial in assessing acute changes or bleeding that could influence treatment decisions in a suspected cerebrovascular accident (CVA). While addressing symptoms like headache and nausea is important, ruling out acute changes in the brain with a CT scan takes precedence in this situation. Collecting blood for coagulation times may be necessary but is not the initial priority. Obtaining a history of medication use, recent surgery, or injury is also important but not the first action to take when a CVA is suspected.

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